Posted on
Monday 4 February 2013

Summary: Academic psychiatry is in trouble, becoming the narrowest of biological research approaches of decreasing relevance to clinical practice and global health. What is required is a rebalancing of the psychiatric academy to include greater support for researchers conducting social, clinical and community studies within a broad, more humanistic biosocial framework.

There is a distortion in academic psychiatry. It seems that a younger generation of psychiatrists is more willing than their senior colleagues to join the chorus of critics outside and inside the broader mental health field to name it and offer a correction. Academic psychiatry has become more or less irrelevant to clinical practice and to the major developments in the mental health field. After decades of investment in biological psychiatric research, there are many intriguing and potentially significant findings, yet still not a single biological test that can be routinely used in the clinic to determine whether someone has a particular mental disorder. Brain science has advanced impressively for neurological conditions, and for our general knowledge of how the brain works, but it has not determined what causes schizophrenia, depressive disorder or anxiety diseases. For all the efforts going into neuroimaging, genetic research, neurophysiology and cognitive neuroscience, which have contributed importantly to our understanding of the brain, we still do not understand the pathophysiology of these mental illnesses or of other psychiatric conditions, from eating disorders to autism.

This should count as an extraordinary failure – one that is apprehended by the pharmaceutical industry, which is clearly moving away from mental disorders to treatment for neurodegenerative diseases and other seemingly more tractable problems. And yet academic psychiatry and the funders of research still proceed as if the great breakthrough is just around the corner. Perhaps the senior generation of researchers has simply become far too comfortable with the financial and media support it has enjoyed over the years. Entrapped by the unlikely prospect of an imminent breakthrough, and the alluring publicity of the latest candidate finding, no matter how shaky, they and the media continue to make immodest claims of causality, inured it seems to the sad embarrassment of having to resort to the difficult-to-say-with-a-straight-face chestnut, ‘It’s all terribly complicated’. Surely, the lesson to be learnt is that biological psychiatry research is necessary but insufficient for a robust academic psychiatry oriented to understanding and treating serious mental illness. Psychosocial, cultural, clinical, health services and policy studies are just as essential as biology in addressing problems that are also social, moral and economic in their genesis and alleviation…

I got this far reading this editorial, and I stopped. I couldn’t see the words. I guess my guard was down, and the moistness in my eyes snuck up on me. Dr. Kleinman is a psychiatrist using a phrase like "conducting social, clinical and community studies within a broad, more humanistic biosocial framework" without even looking over his shoulder to see if anyone is sneering or glazing over. When he talks about the state of affairs after all these years of an obligatory biological psychiatry, he comments that "this should count as an extraordinary failure" and "yet academic psychiatry and the funders of research still proceed as if the great breakthrough is just around the corner" in a simple, matter-of-fact way – like those things are as self-evident as they actually are. And he’s not hostile towards biological psychiatry. He doesn’t brand anyone with devious motives or attack. He just says that "academic psychiatry has become more or less irrelevant to clinical practice and to the major developments in the mental health field" – which is, of course, true, but rarely spoken aloud.

You can read Dr. Kleinman’s story here. It begins: "Dr. Arthur Kleinman is the Esther and Sidney Rabb Professor, Department of Anthropology, Harvard University and Professor of Medical Anthropology in Global Health and Social Medicine and Professor of Psychiatry, Harvard Medical School." He writes books like "What Really Matters: Living a Moral Life Amidst Uncertainty and Danger" and "Deep China: The Moral Life of the Person. What Anthropology and Psychiatry Tell Us About China Today." He’s one of those academics that inspire students and enrich the experience of clinicians, maintaining an editorial attitude towards the human condition that can be integrated into their own work with the individual patients who seek their counsel – and passed along to them.

His book, "Rethinking Psychiatry" came out in 1988, the year after Prozac, the year of the DSM-IIIR. I’d forgotten about it. Parts are available as a Google Book on the Internet. It was about his own field and the relationship of Psychiatry to the Social Sciences. It has a discussion about diagnosis that I recall with a warm nostalgia. But it came out at a time when mainstream psychiatry couldn’t have been less interested in the thoughts of an egghead from Harvard that goes "From Culture Category to Personal Experience." I read it around the time I was leaving academia. I had realized that his kind of "Rethinking Psychiatry" wasn’t going to be happening in the near term. I think I actually felt nostalgic when I read it twenty-five years ago.

Dr. Kleinman lives in the world of academia, so this editorial is a pitch for more funding for and emphasis on psychosocial research, as well as a commentary about the state of academic psychiatry with suggestions for a change in direction, for a rebalancing:

It is the psychiatry of the academy, then, not clinical psychiatry, that needs help. What needs to be done is to complement the best of the biological research effort with equally strong and well-supported research in global mental health and clinical psychiatric practice, involving the community as well as the clinic. We need greater attention to implementation of research in global mental health, to community programmes, consultation–liaison activities, the routine conundrums of the practising consultant and primary care worker and to the questions of coping and caregiving facing patients and families, in order to develop a more practically useful biosocial framework.

To accomplish this rebalancing, the ties between psychiatry and public health need to be strengthened, as should those between our discipline and the social and behavioural sciences. It is telling that most of the MD and PhD students whom I have trained in medical anthropology have chosen to work in the infectious disease field and other subdisciplines of internal medicine. When I began to combine psychiatry and anthropology in the 1970s, academic psychiatry was the most open of the academic medical specialties to its social context, cultural patterning and therapeutic relationships, and to the insights of the social and behavioural sciences. Now it seems that psychiatry is more indifferent and less welcoming to the contributions of social science research than is internal medicine or public health.

Another blurry vision moment. In my case, psychiatry was a solution to being of two minds – a bench scientist who was also drawn to the other side of the campus. And as an Internist, I came to seen doctoring as more than medicine-giving, but also care-taking. The psychiatry I came into split the difference on both counts. And then one day it didn’t. After leaving academia, I wasn’t bitter – more like lonely. I’m more physician than egghead, but I counted as precious my time thereafter teaching in the analytic institute and in the college with the kind of thinkers I encountered there. My interest was in the mechanisms of persistence in traumatic mental illness, and Emory had a collection of people in the Departments of Anthropology and Comparative Literature who were world class scholars in that area, filling my need for people the likes of Dr. Aurthur Kleinman. Their influence was a powerful adjunct to my work with patients. But I came to see most of the forces at work in the changes in psychiatry and why things had to be different. From my perspective, the cataclysmic changes in 1980 were beyond excessive and surprisingly exclusionary – but people on the other side of change always feel that way and make their peace elsewhere.

What saves psychiatry is its clinical utility and its potential for improving caregiving generally, combined with innovative efforts to make it a leading edge of global healthcare delivery. And what just might make a difference for academic psychiatry is to recast the dominant framework as a biosocial model that marries biological and psychosocial/cultural research in applied research collaborations that address the most salient issues for caregiving. That will require fostering of a new generation of psychosocial researchers and much greater support for global mental health researchers and practitioners and health services and policy researchers.

In an age of funding retrenchment for research, it will not be easy to rebalance the research agenda. But if this is not done, we continue on the current pathway. And if by, say, 2030 we still have no clinically useful biological test for mental disorders and little in the way of new therapeutic agents, academic psychiatry will, I believe, be consigned to irrelevancy that will be ruinous to the profession. In the meantime, every sign suggests that young clinicians and researchers will increasingly be drawn to the fields of global mental health and practical clinical mental healthcare.

Will the psychiatric academy rise to this challenge? Much as I hope so, as a realist I doubt this will happen until such time as the entire academic enterprise in psychiatry is clearly in jeopardy. By 2030, there definitely will be a profession of clinical and community psychiatry, but perhaps there will no longer be many academic researchers in psychiatry. I hope I am proven wrong, but if I am not contradicted by history it will be a sad denouement for a field that could and should not just promise much, but actually deliver on that promise.

I share many of his his concerns about psychiatry’s future at this point. I doubt that the current psychiatric academy can or will authentically make the changes he suggests, or contain the future students he’s talking about, who will likely move towards other venues. I’d like to be wrong about that too. Maybe I am.

But, oddly enough, none of that has anything to do with this blog. Earlier, I said, "I came to see most of the forces at work in the changes in psychiatry and why things had to be different" in a very deliberate way – the word "most" was chosen carefully. I saw things as the swinging of a pendulum, the rise and fall of paradigms, the forces of evolution, even revolution. But I missed one of the forces at work – the one that should have been front and center. Part of why I missed it was that I wasn’t looking – off on a sabbatical of of my own choosing. But the other reason was that it was artfully hidden from view. It was the force of industry on parade, but parading in disguise. In my case, about halfway between my office and the part of the Emory campus where I was then sometimes teaching, Dr. Charlie Nemeroff was building a monument to GlaxoSmithKline‘s Paxil and other products of the pharmaceutical industry. And not that far from Dr. Aurthur Kleinman’s office at Harvard, Janssen was funding Dr. Joseph Biederman’s Center to study the Bipolar Child’s response to their Atypical Antipsychotic Risperdal. And out in California at the University where Dr. Kleinman was educated, Chairman Dr. Alan Schatzberg was founding a company to introduce RU-486, the abortion drug, as an antidepressant with Stanford holding some of the patent rights and securities. In that process, the academic psychiatrist had been renamed – Key Opinion Leader [KOL].

I obviously enjoyed Dr. Kleinman’s editorial and feel sympathetic to many of his thoughts. But I’m hanging out with a different crowd these days, reading a different kind of book. I also chose these words carefully, "I’m more physician than egghead." Right now, the debate about the future of psychiatry isn’t going to be determined by an academic debate about the place of the social sciences. That’s for a later time and those bright future students Dr. Kleinman’s referencing. Right now, the operative topic is a medical issue, like a hospital acquired infection or an invasive parasite – maybe a tumor in need of radical surgery. It’s about the impossibility of even considering the things Dr. Kleinman is talking about in the climate created by the pharmaceutical industry’s bonds with organized and academic psychiatry, and the corruption that resulted from the union. Dr. Kleinman points to the failure of psychiatry’s radical medicalization as "one that is apprehended by the pharmaceutical industry, which is clearly moving away from mental disorders to treatment for neurodegenerative diseases and other seemingly more tractable problems." I think he’s being a bit too generous about their motives, but I do hope that both the neurologists and the pharmaceutical industry have learned something from what happened to psychiatry. A recent presentation by the chairman of psychiatry at Columbia and APA president, Dr. Jeffery Lieberman, was entitled, "Don’t Turn Your Back on Industry, but Keep It Honest." He had it backwards. No matter psychiatry’s fate, the only topic in psychiatry right now is just Keep it Honest. Do that and the future will end up where it’s supposed to be.